Are you a regionally subsidized client? Yes No
Current before and after school location:
Parent/Guardian One
Name:
Address:
Home Tel:
Work Tel:
Work address:
Cell phone number:
Email:
Parent/Guardian Two
Name:
Address:
Home Tel:
Work Tel:
Work address:
Cell phone number:
Email:
Child Information
Name:
Address: Apt #
City: PCode:
Health and Medical Information
Date of Birth (Year / Month / Day):
Tel:
Custody Mother Father Both Guardian
YMCA of OakvilleLicensed Child Care Services
September 2015 to June 2016
P.A. Day and HolidayChild Care Registration Form
Doctor Information
Doctor’s name:
Tel:
Address:
City:
Emergency ContactPlease provide us with two authorized persons
to pick up your child and/or be contacted in the event of an
emergency:
Name:
Tel:
Name:
Tel:
Is your child currently on any medication? Yes No
If “yes” please list types of medication and purpose of
medication:
Program SupportHas your child been diagnosed with special needs
or behavioural needs?
(ie. ADD/ADHD) Yes No
Please specify:
Condition Y N Details
Allergies
Peanut EpiPen Yes No
Bee stings EpiPen Yes No
Medications
Food
Other
Does your child receive additional support in school? Yes NoDoes
your child require one on one support? Yes No
In order to meet the individual needs of your child please list
anything we should be aware of:
Has your child been immunized as required by the Education Act?
Yes No
If No, please explain
Medical treatment waiverIf at any time medical treatment is
necessary for my child, I give consent for treatment to be given. I
give permission for the YMCA of Oakville to contact physician in
case of emergency. I understand that every effort will be made to
contact parent/guardian prior to emergency treatment.
Signature of parent Date:
YMCA of Oakville | 410 Rebecca Street, Oakville, ON L6K 1K7 |
Tel: 905-845-3417 | Fax: 905-842-6792 | [email protected] |
ymcaofoakville.org
Stay connected!
P.A. Day and Holiday dates
Child’s name:
P.A. Days and Holidays CentreOctober 9November 27February 5March
28 (Easter Monday)
April 22April 8
June 3
Winter Break CentreDecember 21December 22 YMCA onlyDecember 23
YMCA onlyDecember 24 7:00 am-4:00 pm only YMCA only
December 29 YMCA onlyDecember 30 YMCA only
YMCA = Peter Gilgan Family YMCA, 410 Rebecca St.
March Break CentreMarch 14March 15March 16March 17March 18
How To RegisterOnline - For your convenience register online at
ymcaofoakville.org (credit card only).
In Person - At the Peter Gilgan Family YMCA (410 Rebecca Street)
by cash, debit, or credit.
Regionally subsidized participants must register in person.
Please complete the registration form and return to Peter Gilgan
Family YMCA at 410 Rebecca Street with written verification from
the Region of Halton.
Please note: Fax and email registrations are no longer accepted.
Please DO NOT fax or email your registration forms.
Locations and HoursAll programs run from 7:00 am-6:00 pm.
Locations vary by date, please check ymcaofoakville.org for P.A.
Day locations. Note: The December 24 and December 31 Winter Break
program operates from 7:00 am-4:00 pm.
Fees$40.00/day
fee.
P.A. Day and Holiday Program LocationsThe following centres will
er P.A. Day and March Break programs: St. Luke, Our Lady of Peace,
St. Bernadette, River Oaks, Pinegrove, Palermo and St. Marguerite.
Our Winter Break program and Easter Monday program is
isit our website at ymcaofoakville.org.
P.A. Day and Holiday Break ProgramsRegistration forms and
information on P.A. Days, Winter Break and March Break programs is
available at your Child Care Centre throughout the school year as
well as posted at ymcaofoakville.org. We recommend that you sign up
for all P.A.Days and Holiday programs you want at the beginning of
the school year as space is limited.
Deliver form to YMCA of Oakville, 410 Rebecca Street, Oakville,
ON L6K 1K7. Please note: incomplete forms will not be
registered.
Note: Registration will not be processed unless accompanied by
full payment.
cash cheque VISA M/C AMEX
Credit card payments are only available when registering online
or in person at the Peter Gilgan Family YMCA.
Cancellation and Refund Policy: Requests for refunds must be
made in writing to the P.A. day. Exceptions will be made for
medical reasons, for which a doctor’s note is required. A cheque
will be mailed or your credit card will be refunded within 14 days.
Refunds are
F ce use only: Date Initials Trx/ /
To receive email information updates on YMCA Before and After
School programs and P.A. Day and Holiday programs, please sign up
through our website at ymcaofoakville.org. You may choose the types
of information to receive and may withdraw your consent at any time
yb changing your subscription preferences or unsubscribing. Please
refer to the Privacy Policy or contact us at
[email protected] a.ca or YMCA of Oakville, 410 Rebecca
Street, Oakville, Ontario L6K 1K7.
YMCA of Oakville | 410 Rebecca Street, Oakville, ON L6K 1K7 |
Tel: 905-845-3417 | Fax: 905-842-6792 | [email protected] |
ymcaofoakville.org
P.A. Day and HolidayChild Care Registration Form
YMCA only
YMCA only
December 31 7:00 am-4:00 pm only YMCA only
YMCA of OakvilleLicensed Child Care Services
September 2015 to June 2016
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